Hipaa Authorization Form printable pdf download

HIPAA Authorization Form

Assistance in Health Claims Administration

To:

Maine Municipal Employees Health Trust

Subject:

Authorization to release health information for claims administration or resolution

I, ____________________________________________ (Member Name), authorize the Maine

Municipal Employees Health Trust to release and discuss my personal health information for the purpose

of (please check all that apply):

 Resolving questions about the payment/resolution of my health / dental / disability / vision

claims (circle applicable plans)

 Resolving questions about my specific claim (please specify provider, date and/or diagnosis):

_______________________________________________________________________

 Resolving questions about my eligibility

 Other (please specify): ____________________________________________________

_______________________________________________________________________

This health care information may be released to ______________________________________________

(Authorized Person’s Name).

This authorization expires on ___________________________________ (date or event – if applicable).

I, ____________________________________________ (Member Name), understand that I may revoke

this authorization at any time by providing the Maine Municipal Employees Health Trust with written

notice that I am revoking this authorization.

I also understand that I may not revoke this authorization to the extent that ________________________

(Authorized Person’s Name) and Maine Municipal Employees Health Trust have acted in reliance upon

this authorization prior to the date I revoke this authorization.

I acknowledge that I have received a written copy of this authorization and I understand that I am not

required to sign this authorization as a condition of eligibility in the health plan or payment of benefits.

I have read and understand all of the notices set forth above.

Member Signature: _______________________________ Member SS# ____________________ Date:________

Witness Signature: ________________________________ Witness Name: __________________ Date:_______

(please print)

If the Member listed above is not the covered Employee or Retiree, please complete the following

information:

Employee Name _____________________________________

Employee SS# __________________

Please print

* Authorized Person means the individual to whom you grant permission to speak with Health Trust

personnel regarding your claim(s) and/or coverage. An Authorized Person can be a parent, spouse, child,

co-worker, or any other person who may help you with claim and/or coverage issues.

Hipaa Authorization Form